Question

The nurse has been caring for a client who required a Sengstaken-Blakemore tube because other treatment measures for esophageal varices were unsuccessful. The health care provider (HCP) arrives on the nursing unit and deflates the esophageal balloon. Which assessment finding by the nurse is the most important and should be reported to the HCP immediately?

Answer 1

The most critical assessment finding to report after deflating a Sengstaken-Blakemore tube is evidence of rebleeding or hemorrhage.

Step-by-step explanation:

The most important assessment finding by the nurse after the deflation of the esophageal balloon that should be reported to the health care provider (HCP) immediately would be any evidence of rebleeding or hemorrhage. This could present as fresh bleeding from the mouth or nose, signs of hypovolemic shock such as rapid pulse, low blood pressure, or changes in consciousness. The Sengstaken-Blakemore tube is designed to control esophageal varices bleeding, and upon deflation, the priority is to ensure that this bleeding does not recur, as it can be life-threatening.